LAW ENFORCEMENT/COURT REFERRAL FORM MISDEAMENOR CHARGES ONLY

Referral Date Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively

Case or Docket # This field is required

Charge(s) This field is required

Additional Charge This field is required

Youth's Name This field is required

Gender This field is required

Date of Birth Please provide the month, day, and year in 2 digits, 2 digits, and 4 digits respectively

Parent/Guardian Name This field is required

Relation to Youth This field is required

Address This field is required

Phone Number Format must be 123-123-1234. This field is required.

Email Please provide a valid email address

Primary Language other than English Yes No Please select at least one option

If yes, please specify other language(s)

Family Notified of Referral? Yes No Please select at least one option

If no family contact has been made, please specify the reason

DCFS or OJJ involved with the Youth? Yes No Please select at least one option

If yes, please specify

Additional Comments or Concerns

Referral Agency This field is required

Name This field is required

Phone Number Format must be 123-123-1234. This field is required.

Contact Email Please provide a valid email address